Document 5kVnwa9zXZLXovMbo2OOgg710

FILE NAME: New York State & NY Times (NY) DATE: 1952 DOC#: NY010 DOCUMENT DESCRIPTION: Journal Article - Occupational Disease Diagnosis [Author - Dr. Mayers of the NY Dept of Labor] j any atrial uv . # vv \fs M $r THE PROGRAM OF THE NEW YORK STATE OCCUPATIONAL CANCER COMMITTEE MAY R. MAYERS, M.D. NEW YORK r HE NEW 1947 as an lygiene and YORK State Occupational Cancer Committee was outgrowth of a conference called by the Division Safety Standards for the purpose of reviewing, with a organized in of Industrial group of experts, ue prevention of bladder cancer and the effectiveness of existing control measures u two aniline-dye plants in New York State. The discussion of how to control ertain known carcinogenic hazards in industry very naturally led to a consideration f other occupational causes of cancer, of the fact that there might very well be in .he industrial environment carcinogens which are not even suspected at the present ume, and how one would go about finding them. There was so much interest on the part of those present that the New York State Occupational Cancer Committee was formally organized to study these prob lems. Its membership was as follows: May R. Mayers, M.D., chairman, Division of Industrial Hygiene and Safety Standards, Mew York State Department of Labor, N ew York. Austin V. Deibert,1 M.D., Cancer Control Brnch, National Cancer Institute, Bethesda, Md. Konrad Dobriner, M.D., Sloan-Kettering Institute for Cancer Research, N ew York. Harold F. Dorn, Ph.D., Biometrics Section, National Cancer Institute, Bethesda, Md. G. H. Gehrmann, M.D., Manufacturing Chemists Association, Wilmington, Del. (represented by Dr. Allen J. Flem ing). Paul R. Gerhardt, M.D., Division of Cancer Control, N ew York State Department of Health, Albany, N . Y. Hyman Goldstein,2 Ph.D., Division of Cancer Control, N ew York State Department of Health, Albany, N . Y. Leonard Greenburg, M.D., Division of Industrial Hygiene and Safety Standards, N ew York State Department of Labor, New York. Arthur E. Hoag, M.D., Socony-Vacuum Oil Company, Inc., New York. LeRoy S. House, M.D., Tumor Clinic Association, New York State. W . C. Hueper, M.D., Cancer Control Branch, United States Public Health Service, Bethesda, Md. Louis C. Kress, M.D., Roswell Park Memorial Institute, Buffalo. Anthony J, Lanza, M.D., Institute of Industrial Medicine, New York University-Bellevue Medical Centre, New York. Morton L. Levin, M.D., N ew York State Department of Health, Albany, N. Y. George T. Pack, M.D., Medical Society of the State of New York. Address presented at a meeting of the Cancer Prevention Committee in N ew York on Dec. 3, 1951. Dr. Mayers is Chief of the Medical Unit, Division of Industrial Hygiene and Safety Stand ards, New York State Department of Labor, and Chairman of the New York State Occupational Cancer Committee. 1. Dr. Deibert is now with the Economic Cooperation Association, Washington, D. C. 2. Mr. Goldstein is now with the National Institute of Mental Health, Washington, D. C. 279 fi i a 280 INDUSTRIAL HYGIENE AND OCCUPATIONAL MEDICINE The first activity of the Committee (and its most concrete accomplishment to date) was the preparation and distribution of an educational publication, entitled "Occupational Cancer: A Challenge to the Physician." In this, an effort was made to capture the interest of the medical profession; to stress the importance of an occupational history; to provide the practicing physician with concrete data as to occupational carcinogens, either known or suspected, together with the precancerous lesions associated therewith, and to stimulate more complete and more accurate reporting of cancer deaths. This publication, sponsored by the Medical Society of the State of New York, the New York State Department of Health, and the New York State Department of Labor, was distributed to every physician in the state. It has since been reprinted by the Committee and continues to have a wide on-request distribution. It has also been reprinted in various medical journals.8 At this point, the National Cancer Institute, already represented on the Com mittee, provided the necessary funds for a pilot study of occupational causes of cancer. A two-year study was originally contemplated. However, the grant has since been extended for a third and last year, which is soon to expire. Preliminary to the formulation of a definite program, the Committee gave long and careful thought to the complexities of the industrial environment and par ticularly to the many problems involved in any effort to discover unsuspected car cinogenic agents that might be present therein. Certain basic considerations, such as the following, largely determined the type of study which was finally agreed upon: 1. The striking increase in the incidence of cancer--particularly, lung cancer---has apparently coincided with advances in technological research and development in this country, and causal relation must be considered a possibility. 2. The increasing complexity of the industrial environment has exposed workers to an everincreasing number and variety of physical and chemical agents---particularly to chemical con taminants of the air in the workroom, in the form of noxious dusts, gases, fumes, vapors, mists, and the like. 3. The multiplicity of abnormal environmental factors to which any individual worker may be exposed in the course of a long working life is further complicated by his great mobility (i. e., he is apt to drift from one industry to another) and by the fact that the principle of synergism may assume an important role, particularly when the worker has been simultaneously exposed to more than a single toxic agent. 4. Individual chemical and physical agents in the industrial environment are not necessarily or even usually pathognomonic for particular industries or occupations. They may be found widely distributed among many totally unrelated types of work. Common denominators of "exposure" in industry as a whole, therefore, assume great significance. 5. Conversely, a particular job classification does not necessarily provide precise information as to the nature of the occupational exposure. To say a worker is a "foundryman," for example, means little for this purpose. It makes a great difference whether he is a molder who handles dry sand; whether he pours molten metal containing lead or other toxic materials; whether he is a sandblaster, or operates a crane. 6. Accurate and complete occupational histories of patients are difficult to obtain because of the technical complexities of the materials handled and the failure of patients to present the whole story. Even a well-informed chemist who contracts an occupational disease in his labora- 3. The New York State Occupational Cancer Committee Presents a Program on Occu pational Cancer, Compens. Med. 3 :9 (Sept.-Nov.) 1950; Occupational Cancer: A Challenge to the Physician, Month. Rev., New York State Dept, of Labor 30:37 (O ct.) and 44 (N ov.) 1951. .iiin iii mmm m iitim 'MltfiiV )ICINE omplishment to -1cation, entitled effort was made .nportance of an ::rete data as to die precancerous i more accurate dical Society of [h, and the New an in the state, wide on-request ad on the Comaional causes of , the grant has TO. nittee gave long ament and paransuspected cariderations, such a finally agreed a r--has apparently aintry, and causal orlcers to an ever . to chemical connes, vapors, mists, /dual worker may eat mobility (i. e., . iple of synergism Uaneously exposed are not necessarily aey may be found a denominators of -recise information nan," for example, alder who handles . rials; whether he to obtain because iits to present the rase in his labora- rogram on Occu r : A Challenge to 144 (Nov.) 1951. MAYERS--NEW YORK STATE OCCUPATIONAL CANCER COMMITTEE 281 tory will not necessarily, when asked, give a complete list of all the substances he handles. He tends rather to be selective and to list only the substances of which he is suspicious. Failure of memory for occupations years back obviously complicates the problem. 7. Little is known about duration or intensity of exposure in relation to cancer production even in the case of known carcinogenic agents, and the latent period is extremely variable-- sometimes 25 years or longer. 8. Individual differences in susceptibility to occupational cancer appear to be as great as in every other branch of medicine. 9. Cancer site appears to have no relation to the precise portal of entry. Thus, the inhalation of beta-naphthylamine results in cancer of the bladder, not of the lungs. 10. Toxic agents are not necessarily carcinogenic and vice versa. Therefore, techniques for control of the industrial environment based on maximum allowable concentrations or on particle he will not necessarily be effective when a carcinogen is present in the workroom. 11. Known physiological and biochemical mechanisms involved in the production of occu pational diseases due to toxic agents, radioactive substances, acute or chronic irritants of the kin or the respiratory passages, sensitizing agents, and the like may be quite different from those operative in the field of occupational cancer. For example, among the pneumoconioses, t is not at all clear why asbestosis appears to be associated with lung cancer while silicosis is not. 12. A study of death certificates has serious limitations in that only the last occupation is given, whereas some previous occupation, 15 or 20 years earlier, is far more likely to have been the cause. Then, the occupation given is not always accurate, or may be stated in such general terms, such as "Laborer," that it is difficult, if not impossible, to know what the patient's environmental exposures were. There may also be serious doubt as to the accuracy of the diagnosis, particularly as it relates to the primary cancer site. Furthermore, the death certificates record "cancer" only for those persons who actually died of cancer. They do not indicate cancer patients who had recovered or who died of one or another unrelated condition, such a s; diabetes or coronary thrombosis. In any study of occupational causes of cancer, such patients are obviously quite as important as the ones who died of cancer. After deliberating for some time on the foregoing points, the New York State Occupational Cancer Committee decided to embark on a program which would involve taking detailed and complete occupational histories on a series of live cancer patients, starting with their present work and going all the way back to their first job. The statisticians in the group helped develop the "forms" which were used. These forms called for (a) medical data from the hospital records; ( b) occupational history, and ( c) the use of a check-list of "exposures." The occupational-history forms went beyond conventional job and industry classifications to inquire into the actual work done by each patient in each of his jobs. Inquiry was also made as to his environmental exposures on each job so far as he knew, using a check-list pro vided for the purpose. Inquiries as to hobbies and "work after hours" involving the use of paints, solvents, insecticides, pesticides, and the like were also included. The plans called for occupational interviews, along the lines above indicated, on an unselected series of 6,000 male adults under 75 years of age coming to the Ros well Park Memorial Institute, Buffalo, for diagnosis or treatment. This hospital was selected because it is the largest state cancer hospital and because here one could be sure of a complete medical work-up in each case with the necessary patho logical data and an accurate diagnosis of primary cancer site. It was anticipated that about 1,000 of these patients would turn out not to have cancer and could thus be used as controls. The interviewers were given some preliminary training by the statisticians on the Committee, and they did their work under the immediate direc tion of Dr. Louis Kress, medical director of the Institute. Actually, as the deadline 282 INDUSTRIAL HYGIENE AND OCCUPATIONAL MEDICINE of the grant-in-aid approaches, approximately 4,500 patients have been interviewed and about 750 noncancer controls have been obtained. As the interviews were completed, they were forwarded each week to the Division of Industrial Hygiene and Safety Standards, where, with the assistance of two industrial-hygiene chemists, under the direction of the Committee's chairman, each occupation given by each patient was carefully evaluated from an industrial hygiene viewpoint. Supplementary data were appended to each patient's record, indicating the abnormal environmental exposures known to specialists in the field < of industrial hygiene as being commonly associated with each job. This work has now been completed. The patients' completed records have been forwarded to Dr. Gerhardt, director of the Division of Cancer Control, New York State Department of Health. Under his direction, these data are now being coded and put on punch cards to be run through I. B. M. machines. Statistical analysis of the data is still in progress. What this study will ultimately contribute in the way of extending present knowledge of the occupational causes of cancer is for the future to decide. There was no thought to get definitive data at this time but, rather, to get leads for more intensive study later on. Within the more limited canvass provided by such leads, it is hoped, field investigations--including chemical air analyses and dust counts, when necessary--will provide more detailed information with reference not only to suspected carcinogenic agents in the occupational environment but also to duration and intensity of exposures in relation to the development of occupational cancer. The industrial hygiene slant which has characterized the study in New York State has resulted in the development of a considerable volume of data--never before collected--with reference to specific physical and chemical agents to which cancer patients had been exposed in the course of their work. The large number of vari ables thus introduced has, however, created very real problems for the statisticians. But, these variables are the very essence of the industrial environment which is as. under investigation, and ultimately they will have to be taken into account. Perhaps, with so many variables, one requires a far larger series of cases than the 4,500 w'hich have become available as a result of the present study. Perhaps, complex data of this type will never serve too well the mass-statistical approach; what may be required is a purely medical evaluation by an astute clinician. Doctors of industrial hygiene, for example, are accustomed to dealing with large numbers of variables per patient in connection with all field studies. Here, analogous data on the occupational environment are collected, and to these are added data derived from occupational and clinical histories, physical examinations, and laboratory and x-ray findings, The number of workers usually included in these studies is rarely large enough for mass-statistical analysis. But clinical analysis has made funda mental contributions to industrial toxicology and has provided a basis for the estab lishment of accepted safe standards for purposes of prevention (so-called maximum allowable concentrations). The independent experience now being developed in the pilot studies which are in progress in the several states may provide an answer. New York State was the first to embark on such a study and the first to receive a grant for this purpose from the National Cancer Institute. Its situation differs from that of the other states in that its study is being carried out by a distinguished MAV: i committee, participant meat: prop It is all its own ser, si ve. P e rh . reutly and utilizing su m e n 's coni; by social-S' vast fund o of persons future bere taking add Dr. Kmi industries to Dr. Maa history by i tonus of do gone out of as to make study is exk P rof. K. or do they o Dr. Ma . covered lli.u which is lai Du. t .t:i ' rural popul; Die Ma coded. Dal; Dr. E mi your list ui uiticant coir Dr. M u which wore envirounnuu CINE en interviewed . week to the e assistance of ee's chairman, i an industrial uient's record, its in the field This work has hardt, director lealth. Under a ds to be run progress, nding present decide. There leads for more by such leads, 1 dust counts, ce not only to iso to duration mul cancer, in New York --never before <which cancer amber of variie statisticians, ment which is count. , of cases than udy. Perhaps, deal approach; an. Doctors of ,;o numbers of iogous data on 1 data derived laboratory and udies is rarely > made funda ; for the estabdled maximum veloped in the an answer, first to receive uiation differs . distinguished MAYERS--NEW YORK STATE OCCUPATIONAL CANCER COMMITTEE 283 committee, with representatives of various state and federal agencies among the participants. Elsewhere, these studies are being conducted as State Health Depart ment projects. It is already becoming evident that each of the pilot studies now in progress has its own serious limitations and that all are unexpectedly time-consuming and expen sive. Perhaps, the ultimate approach will be found in starting noiu to collect cur rently and compile accurate occupational data for analysis 15 or 20 years hence, utilizing such social-security records as unemployment insurance, placement, work men's compensation, sickness insurance, and the like. The "forms" now being used ay social-security agencies and other groups could be so modified as to provide a .ast fund of information for the future, as to the successive environmental exposures of persons in whom cancer ultimately develops. However, whether this vision of uture benefits will be sufficiently inspiring to overcome natural resistance to underuiking additional work in the present carries a big question mark. ABSTRACT OF DISCUSSION Dr, E merson Day, New York: Has your group made any effort to contact officials of industries to verify exposures reported by the patients interviewed? D r. M ayers : In the beginning the Committee planned to check each patient's occupational history by field visits and even by air analyses and dust counts to get data as to exposure in icrms of dosage. It was soon discovered, however, that tins was not practicable. Plants had gone out of business or were found to be operating so differently since the patient worked there is to make the investigation useless. It is hoped that this approach may be utilized when the itudy is extended to follow up specific leads which may be developed. P rof. E. V. Cowdry, St. L ouis: Do your records comprise a considerable variety of industries >r do they tend to be restricted to those industries that happen to be located in the Buffalo area? D r. M ayers: W e have encountered a very wide range of occupations. However, we dis covered that the hospital selected draws most of its patients primarily from Up-State New York, which is largely agricultural, but also has most of our large chemical industries. D r. L eslie Beard, New York: Have you any data on cancer in urban as compared with rural populations? D r. M ayers : Information as to residence was an item in the questionnaire and has been coded. Data on this point should come out of the analysis. D r. E merson D ay, New York: I notice that there are several hundred different items in your list of exposures. Do you feel that you have obtained enough histories to provide a sig nificant concentration of data for any particular item or group of items? D r. M ayers: The large variety of exposures involved in this study is one of the difficulties which worry our statisticians. These many variables are essential characteristics of the industrial environment and will have to be met ultimately in one way or another. I ' j U: :i; MIiLll !- I 1 i **#1, ** 'Jt&L J\4- A. M. A \> v a r c h i v e s of Industrial Hygiene and Occupational Medicine EDITORIAL BOARD PHILIP DRINKER, Chief Editor 55 Sliattuck Street, Boston 15 THEODORE F. HATCH, Pittsburgh OSCAR A. SANDER, Milwaukee IEN N E. POOLE, Glendule, Calif, WILLIAM A. SAWYER, Rochester, N Y FRANK PR1NCI, Cincinnati HERBERT E. STOKINGER, Cincinnati ' JAMES H. STERNER, Rochester, N. Y. RICHARD J. PLUNKETT, M.D., Chicago, M anaging Editor Volume 5 1952 PUBLISHERS AMERICAN MEDICAL ASSOCIATION CHICAGO 18, ILL. m A. M. A A Il C H I V E S O F Industrial Hygiene and Occupational Medicine EDITORIAL BOARD PHILIP DRINKER, Chirr Editor S h a t t u c k Str eet. Po s to n 1 T H E O D O R E E. HATCH. P it tsb u r g h OSCAR A. SA N D ER , M i lw a u k e e P E N N E. P O O L E , Elenchile, C alif. W IL L IA M A. S A W Y E R . R o c h e s te r , N. Y. PRANK PRENCI, C incinnati H ER H ER T E. STOKINCER, C incinnati J A M E S H. S T E R N E R , R o c h e s te r , N. Y. RICHARD J. PLUNKETT. M.D., Chicago, Managing Editor 0 VP pu>iiv/"n? RiCr V ole m e 5 1952 TOMPKINS-McCWV LIBRARY NOV 18 1952 i MED. C U I . o VA. j R I C H M O_N__D----, ----V----\-- i PLBLISH LBS AMERICAN MEDICAI. ASSOCIATION CH IC AG O 1, ILL. 51362 F.